Diabeti dhe komplikimet Erëblin Lahu

Përgjigje-Kumar&Clark’s Clinical Medicine Erëblin Lahu

Diabeti dhe komplikimet l 2021 tiple

NSWERS
Answer 1
Insulin promotes active transport of glucose into the cell (using the glucose
transporter GLUT 4) and this is accompanied by potassium transport.

Answer 2
We can see no reason for the change that is occurring in your primary
care practice. The difference between fasting and postprandial
measurements might be related to insulin resistance in type 2 diabetes
but it also relates to changes in lifestyle, i.e. food intake and exercise.

Answer 3
The diagnosis for diabetes mellitus is a fasting plasma glucose greater
than 7 mmol/L (126 mg/dL) or random plasma glucose greater than
11.1 mmol/L (200 mg/dL). Two abnormal values are required in an
asymptomatic patient to indicate impaired glucose tolerance are shown
in Box 19.1.

Answer 4
The diagnosis is made on:-symptoms of diabetes and a random plasma
glucose of _200 mg/dL (11.1 mmol/L or a fasting plasma glucose
_126 mg/dL (7.0 mmol/L). This also applies to children.

Answer 5
Glycosylation of haemoglobin results in the formation of a covalent bond
between the glucose molecule and the terminal valine of the beta chains of
the haemoglobin molecule. The rate at which this occurs is related to the
prevailing glucose concentration. HbA1C is expressed as a percentage
of the normal haemoglobin, and normal is 4–6.2%. This test provides
an index of the average blood glucose concentration over the life of the
haemoglobin molecule, about 6 weeks. It therefore gives a more general
picture of the blood glucose level than a single blood glucose.
Box 19.1 Definitions
Impaired fasting glucose (IFG)
American Diabetes Association criteria is a plasma glucose level of
5.6–6.9mmol/L (110–126mg/dL)

Impaired glucose tolerance (IGT)

Fasting plasma glucose _7 mmol/L (126 mg/dL). At 2 h following a 75-g
glucose load: 7.8–11 mmol/L (140–200 mg/dL)
Note: both IFG and IGT are risk factors for the development of diabetes and
cardiovascular disease
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Answer 6
Both the random blood sugar and the fasting blood sugar are of some
Diabeti dhe komplikimet Erëblin Lahu

use in the management of type 2 diabetes. However, both are isolated

measurements. It is much more useful to get patients to measure their
own blood glucose three or four times a day, say at 3-weekly intervals.
An alternative is to use the glycosylated haemoglobin level, which is the
best guide to overall blood sugar levels over the preceding 3 months.
In both type 1 and type 2 diabetes, good control reduces the risk of
complications. Your patient should therefore be encouraged to keep a
normal blood sugar and a normal level of glycosylated haemoglobin.

Answer 7
Any high blood sugar, whether fasting or random, indicates diabetes but
single tests, e.g. in the clinic, are of limited value. Help your patients to
do their own blood testing at home.

Answer 8
It is better to use the glycosylated haemoglobin (HbA1C) level; the ideal is
_7% and the patient does not need to be fasted.

Answer 9
The best approach is for the patient to do blood sugars at home
throughout the day, with HbA1C being performed at the clinic visit.

Answer 10
Two-hour postprandial blood sugar is not as good a measurement as
HbA1C, which should be less that 7%. If the level is higher, the oral
diabetic therapy should be increased if possible. However, do not
hesitate to start insulin therapy sooner rather than later.

Answer 11
BM stands for Boehringer Mannheim, the firm that produces a number of
glucose measurement strips.

Answer 12
Glycosuria occurs when the blood glucose level exceeds the renal
threshold. This threshold varies, and fluid intake affects urine glucose
concentration. A negative urine does not distinguish between hypo-,
normo- or even slight hyperglycaemia. For these reasons, diabetic control
is monitored using blood samples obtained at regular intervals by the
patient. However, in a stable type 2 diabetic whose urine is always
negative and occasional blood glucose tests are normal, urine tests can be
used if the patient refuses to do regular blood tests.
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Answer 13
No, it is not a good idea because refined sugar will produce abrupt
swings in glucose level due to rapid absorption. Better to eat an apple!

Answer 14
Impaired fasting glucose carries the same risks of cardiovascular disease
Diabeti dhe komplikimet Erëblin Lahu

and future onset of diabetes as impaired glucose tolerance. So, yes,

metformin is used in these patients.

Answer 15
Impaired glucose tolerance is a risk factor for future diabetes and
cardiovascular disease. Therefore, many diabetologists start metformin
therapy (Fig. 19.1).

Answer 16
Fortunately, the Muslim faith does not require insulin-dependent
diabetic patients to fast during Ramadan. Some patients do, however,
decide they would like to fast.
One regimen is for the patient to run on a bed-time injection of insulin
glargine. This long-acting insulin acts over approximately 24 hours and
will often provide sufficient basal insulin to carry the patient through
from bed time to the evening of the next day. The size of the insulin
glargine (basal) injection is adjusted during the year to get pre-breakfast
blood glucose readings of 5–7 mmol/L.
On top of the basal insulin, the patient injects a rapid-acting, rapidly
disappearing insulin whenever he or she eats. During the year this will
be three times a day. During Ramadan it will be twice a day (before
sunrise and after sunset).
The meal-time insulin is adjusted to the size of the meal on the plate,
aiming to get a home blood glucose reading of 5–8 mmol/L 2 hours
postprandially. Trial and error is needed for each patient to be able to
‘guestimate’ how much insulin goes with a meal of a given size. This
regimen is also used in shift workers.

Answer 17
Pioglitazone and rosiglitazone are the two glitazones available in the
UK. They act by reducing peripheral insulin resistance. The current
recommendations are that glitazones should be used in patients who are
unable to take metformin and a sulphonylurea, or for those whose blood
sugar remains high on this combination.
There are rare reports of liver dysfunction, and monitoring of liver
biochemistry is necessary every 2 months for the first year. These drugs
can also cause salt and water retention, giving oedema and rosiglitazone
Diabeti dhe komplikimet Erëblin Lahu

which has been linked with increased cardiac events.

208
Answer 18
It makes no difference.

Answer 19
Glibenclamide was shown in one trial to be safe in pregnancy; it does not
cross the human placenta. However, most diabetologists do not use oral
therapy in pregnancy.
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Answer 20
No, it is not always necessary. However, the group of patients over
50 years of age with a coronary heart disease risk greater than 15 over
the next 10 years will include many people who are diabetics, and they
should be given low-dose aspirin.

Answer 21
The statement that you should ‘avoid tablets before the age of 40 years’
is a reference to the fact that below 40 years most patients have type 1
diabetes with insulin deficiency and therefore require insulin therapy.

Answer 22
1. Yes – use insulin in all type 2 patients if glycosylated haemoglobin
(HbA1C) is _9.0%. It is better to start insulin therapy early than to wait.
2. Failure of control using oral agents, including the glitazones. Weight
Diabeti dhe komplikimet Erëblin Lahu

gain is a problem with insulin therapy.

Further reading
Nathan DM (2006) Thiazolidinediones for initial treatment of type 2 diabetes?
New England Journal of Medicine 355: 2477–2480.

Answer 23
Beta-cell function steadily decreases in type 2 diabetes. No improvement
in functional capacity of beta-cells would occur with insulin therapy.

Answer 24
1. Inhaled short-acting insulin was available but has now been
withdrawn because of limited clinical demand.
2. Insulin, like other proteins, is broken down in the gut so oral insulin is
not feasible unless some special coating of the tablet could be found.
Nothing is in sight at the moment.

Answer 25
There are very few complications. Antibodies can be demonstrated in
the serum but rarely cause a problem. Patients can react to the protamine
added to make long-acting insulins. Weight gain can be a problem and
needs to be monitored. Many patients feel hungry on insulin and a
reduction in dose may be required.

Answer 26
In 1976, Alberti published a paper on using small doses of either
intramuscular or intravenous insulin for the treatment of diabetic
ketoacidosis. Prior to this, large doses of insulin had traditionally
been used.
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Answer 27
There is no role for steroids, even in resistant diabetes.

Answer 28
Insulin therapy drives K into the cell and hypokalaemia can result.
Hence always give K 20 mmol/L of 0.9% saline.

Answer 29
30–300 mg in 24 hours is called microalbuminuria. In type 1 diabetes, if
microalbuminuria is persistent despite good glycaemic and lipid control,
an ACE inhibitor should be used. In type 2 diabetes, an ACE receptor
blocker is preferred.

Answer 30
Frank proteinuria, i.e. >300 mg/day, should be treated with an ACE
inhibitor/antagonist after good glycaemic and lipid control has been
instituted. A ratio of 30 would also indicate the necessity for treatment.
Diabeti dhe komplikimet Erëblin Lahu

Answer 31
Nicorandil probably is no better than any of the other drugs that are used
for the treatment of angina.

Answer 32
2.5 mg methyltestosterone is a very small dose and should be safe in
diabetics. It is, however, difficult to see an indication for this therapy.

Answer 33
The mechanism of atherosclerosis is not clear but probably includes:
● Endothelial dysfunction.
● Abnormalities of coagulation, particularly in the fibrinolytic pathway.
● Plaque composition: there is increased lipid and macrophages in
plaques in diabetes mellitus which increase the risk of rupture.
● Platelet activation leading to aggregation.
Further reading
Gaede P et al. (2003) Multifactorial intervention and cardiovascular disease in
patients with type 2 diabetes. New England Journal of Medicine 348: 383–393.

Answer 34
The pathogenesis of the renal complications of diabetes mellitus is still
not completely understood.
In general, the conversion of glucose to sorbitol via the polyol pathway
seems to play a central role as this leads to vascular permeability and
structural defects in capillaries.
In the kidney, the glomerular filtration rate (GFR) is initially
increased out of proportion to plasma flow owing to an elevation in the
transglomerular pressure gradient. The raised glomerular pressure might
promote transglomerular passage of proteins as well as glycosylate
end products. This could lead to proliferation of mesangial cells and
accumulation of matrix products in the basement membrane. These are
the first changes seen pathologically when microalbuminuria occurs.
These changes eventually lead to glomerular sclerosis with progressive
loss of glomeruli and more marked proteinuria.

Answer 35
You are correct, but there are of course many more cases of type 2
diabetes; hence this is the most common cause.

Answer 36
Delayed gastric emptying has been demonstrated in approximately 50%
of unselected usually asymptomatic patients with type 1 diabetes. There
is usually evidence of an autonomic neuropathy and often a peripheral
neuropathy. There is, however, no good correlation between the motility
findings and the symptoms. A few patients do develop severe vomiting.
In addition, hyperglycaemia per se inhibits gut motility.
Treatment consists of very good glycaemic control. Metoclopramide,
domperidone or erythromycin (this acts on motilin receptors) can also be
Diabeti dhe komplikimet Erëblin Lahu

tried. Hospital admission is occasionally required for dehydration and

control of diabetes.

Answer 37
Gabapentin is effective in painful neuropathy, although trials are small.
It produces many side-effects (look up your national formulary) but on the
whole is well tolerated. It does cause troublesome diarrhoea. Carbamazepine
is also effective but less so. Only two drugs have been approved by the US
Food and Drug Administration based on phase III RCTs: pregabalin (related
to gabapentin) and duloxetine, which inhibit the receptors of serotonin and
noradrenaline (norepinephrine).

Answer 38
In type 1 diabetes there is no or very low insulin available. In type 2,
insulin is present although there is resistance to its action. This is the
reason for diabetic ketoacidosis in type 1 diabetes.

Answer 39
The cause of abdominal pain in diabetic ketoacidosis is not clear.

Answer 40
In ketoacidosis, stix testing of the urine will show very high ketone
levels (grade III). This is occasionally useful if you have any doubt of the
diagnosis. Low levels of ketonuria (grade I) are seen in starvation.
You can also measure ketone levels in the serum; again high ketone
levels are seen in ketoacidosis.

Answer 41
Starvation is the main cause. It also occurs after heavy alcohol consumption
(starvation is also involved as people do not eat when drinking heavily).

Answer 42
The diabetic foot ulcer is not usually caused by trauma where the tetanus
bacillus can be picked up. It is usually the result of neuropathy and/or
ischaemia.

Answer 43
There is some evidence that neuropathies can occur without overt
diabetes mellitus.

Answer 44
It depends on the cause of the vertigo. If the vertigo is due to a brainstem
vascular lesion associated with diabetes mellitus, nystagmus is
frequently present. Transient vertigo occurs with hypoglycaemia without
the neurological signs.

Answer 45
Type 2 diabetes is associated with coronary artery disease, which usually
Diabeti dhe komplikimet Erëblin Lahu

produces left ventricular systolic dysfunction with some degree of

diastolic dysfunction. In chronic stable angina, the diastolic dysfunction is
usually stable except after exercise when ‘demand ischaemia’ occurs due
to increased oxygen demand when there is a decreased coronary flow.

Answer 46
There is good evidence that ACE inhibitors or angiotensin receptor
antagonists are renoprotective. Recent guidelines suggest that the
antagonists should be used first in type 2 diabetes.

Answer 47
Type 1 diabetes is an immune mediated disease and there is some
immunosupression. It has been shown that treatment with an
immunosuppressive drug prolongs beta cell survival, although this is
not used in clinical practice.

Answer 48
Quinine overdose can cause hypoglycaemia but dextrose (10%) infusion
can be used and will prevent severe hypoglycaemia in most cases.
The mechanism of the hypoglycaemia is increased insulin secretion.
Intramuscular glucagon might be of short-term help and Octreotide 50 μg
SC 6-hourly has been used.
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Answer 49
Yes.

Answer 50
LP(a) is associated with an increased risk of coronary heart disease, but
in the patient you describe, who has a normal cholesterol, nothing should
be done.

Answer 51
Milk and other dairy products should be restricted. However, it is only
with severe restriction that a significant effect on cholesterol levels is seen
and this is often unacceptable to patients. Some restriction, plus a statin,
may be a better option.

Answer 52
Yes, with diet and a statin (Table 19.1).

Answer 53
Cholesterol synthesis is maximal in the late evening/early morning, so
that giving a statin at night maximizes its effect.

Answer 54
There is no best statin. When prescribing drugs it is usually wise to use
the drug you know best, not to go immediately for the newest.
Diabeti dhe komplikimet Erëblin Lahu

Answer 55
At least 4 weeks.

Answer 56
None; treatment should only be discontinued if transferases are more
than three times the upper limit of normal.

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Answer 57
Probably forever, as diet modification seldom works.

Answer 58
Lipid/cholesterol deposits in the cornea produce an arcus. In the young,
it is said to be associated with hyperlipidaemia but the exact relationship
is unclear. It has no significance in the elderly as it is a degenerative
process. There is no treatment.

Answer 59
A number of patients with familial hypercholesterolaemia do need an
additional drug. Ezetimibe (a cholesterol absorption inhibitor) should be
added to a statin.

Answer 60
No. Diabetic neuropathy is described on p. 1055 of Kumar and Clark
Clinical Medicine 7th edn, and the sympathetic nervous system can be
involved in diabetes. However, Horner’s syndrome is not described.

Answer 61
Diabetic patients classically have ‘silent’ ischaemia or heart attacks due to
the accompanying neuropathy. They can, however, have typical angina
with chest pain.

Answer 62
A flat oral GTT occurs when there is malabsorption of glucose. It was
used in the 1950s and 1960s as a test to show malabsorption. However,
it was replaced by tests using non-metabolized sugars, such as xylose,
which were more reliable. More recently, absorption tests have been
superseded by imaging, antibody tests and histology of the small
intestine to diagnose malabsorptive conditions such as coeliac disease.
Diabeti dhe komplikimet Erëblin Lahu

Answer 63
Most patients with hypertension and diabetes will require a statin but
before starting this agent you should encourage lifestyle changes, e.g.
stopping smoking, taking regular exercise and reducing fat in the diet.
Use statins to keep serum cholesterol to <4 mmol/L (150 mg/dL).

Answer 64
Vagal damage can lead to gastroparesis but this is usually in type 1
diabetes. There is no correct treatment for nausea and vomiting; meal
changes and antiemetics are the best approaches.

Answer 65
You are right in that hyperkalaemia is more dangerous than
hypokalaemia. However, cardiac arrhythmias do occur with
hypokalaemia.

Answer 66
Diabetes mellitus is of course a risk factor for atherosclerosis, which can
present with, for example, aortic or carotid dissection both associated
with Horner’s syndrome.

Answer 67
Patients resistant to methotrexate are now treated with anti-TNF therapy,
e.g. infliximab.